The above information provided is true and correct to the best of my knowledge. I also understand that what I have disclosed to the healthcare team is deemed as an authorization for the management of my health. The hospital is required to share protected health information of the patient with public health authorities that are authorized by law to collect information regarding notifiable diseases to aid them in their mission of protecting the health of the public. I have read the information mentioned above. I agree to abide by the rules and regulations of the hospital and health authorities.